Excuses galore for refusals, patients feel cheated

Keya Sarkar pleaded helplessly with officials at the insurance counter of CMRI.It was 11.45 pm and her medical insurance card had just been rejected for a cashless benefit.

| TNN | Updated: Jul 11, 2012, 03:24 IST

Case I:Keya Sarkar pleaded helplessly with officials at the insurance counter of CMRI. It was 11.45 pm and her medical insurance card had just been rejected for a cashless benefit. The elderly woman from Behala was at a complete loss. Even as a hospital official argued that her TPA was not eligible for it, she rummaged her purse, searching for money to pay for her husband's ECG. The latter had just been rolled into the cardiac unit following a heart attack. "But I am not carrying enough cash. I must borrow it from a neighbour...," her voice trailed off as she rushed out to arrange for money. Sarkar had to take a taxi back home, borrow money and return to the hospital to make the payment on time.

Case II:Amarnath Mukherjee clutched on to his son's blood-soaked shirt and tried to convince officials at an EM Bypass hospital to admit the accident victim. Thirty-two-year-old Anirban, his son, had just been run over by a truck. Mukherjee was told that though Anirban would be admitted, he must pay for an emergency surgery within 24 hours. "My medical insurance card mentions your hospital on their list. Why won't you allow me a cashless facility?" he asked. "We are no longer allowing a cashless benefit to your TPA. Please don't waste our time," the official replied curtly. Mukherjee had to borrow Rs 1 lakh at a steep interest the next morning. "I have no idea how I am going to repay the loan. I will probably have to approach a bank for a personal loan at a lower interest," he said.

KOLKATA
: Thousands across the city are being refused medical insurance benefits at hospital counters every day. While most are being told that their TPAs are no longer eligible for insurance facilities other than a reimbursement option, others are being turned away on the ground that their illnesses are not covered under the scheme. Yet others are denied reimbursements for failing to furnish documents of previous hospitalizations. Patients' families, who rely on insurance to see them through the treatment without having to shell out a huge amount in cash, are being left in the lurch. Many like Mukherjee are being forced to borrow funds. Others are left with no option but to move their patients to cheaper hospitals, often compromising on the quality of treatment.

Sujit Deb was stunned when told by a corporate hospital that his knee surgery was not covered by his insurance. Deb challenged the claim, but was shown the insurance document that mentioned the ineligibility. "But my agent didn't tell me that some ailments are not covered for the first four years of the policy. This amounts to cheating," Deb fumed. He failed to get in touch with his agent and had to settle for a reimbursement claim. "I had to exhaust my savings to pay for the surgery and had to borrow from a friend for my son's admission to an engineering college. This is unfair," he lamented.

Dulal Roy of Jadavpur faced a similar ordeal. He had to be admitted to a leading city hospital with chest pain. Roy needed an emergency surgery. He had a family floater mediclaim policy with a public sector insurance company, but the hospital, despite being enlisted under Preferred Provider Network (PPN), refused to give cashless facility to Roy citing that it was not dealing with that particular third party administrator (TPA). Roy had no other option but to pay the entire hospital bill and apply for reimbursement.

There are yet others who have gone through even worse. They have been reduced to penury after a stint at the hospital, despite being medical insurance policy holders. Shambhu Nath, a small-time trader from Manicktala, had banked on insurance for his daughter's surgery. Five-year-old Tina, who suffered from a congenital cardiac ailment, needed an emergency surgery last March. Nath was shocked to learn that since it was a 'pre-existing ailment', the insurance company wouldn't pay for it. The super-speciality hospital demanded Rs 3 lakh for the operation. It had to be deposited within a week or else the surgery would stand cancelled, he was told.

Nath mortgaged his two-room flat and sold off his bike to arrange for the money. "I must repay the loan within the next two months or I will be left without a place to live. My daughter's treatment has to continue. Where will I arrange the money from? The insurance company is squarely responsible for my condition," he said.

Shop-owner Ashok Kundu had to cancel his daughter's wedding after being forced to fork out Rs 2 lakh for a cardiac procedure. His TPA was not eligible for a cashless benefit, Kundu learnt after his admission. He was reimbursed less than 60% of the claim. "Honestly, I am not educated enough to read and understand every clause. But it cost me dearly. I exhausted all the money I had saved for my daughter's wedding," he rued.

Hospitals argue that it is primarily the insurance companies' and TPAs' responsibility to make their clients aware of the eligibility clauses. They also accused the TPAs of delaying payment, forcing them to blacklist some. "We are eager to extend cashless benefit to all patients through the PPN and have already submitted a proposal. Once they respond, it will be available to all. But TPAs often act irresponsibly. They deny payments to both patients and us. While it's hard on patients, we, too, face problems. On an average, TPAs take three months to clear our dues which reduces our working capital," said Rupali Basu, CEO of Appollo Gleneagles Hospital. Apollo offers cashless benefit to group insurance and corporate policy-holders.

Ruby Hospital, which has joined the PPN and offers cashless benefit to all patients, agreed. "While insurance policy-holders deserve the cashless benefit, it's the TPAs who have been playing truant. They harass patients, misinform them and refuse to clear our dues in time," said SB Purakayastha, CEO of Ruby.

"Our heart goes out to the patients. They deserve all the help and we try to assist them to the extent possible. But unless TPAs cooperate, the problem won't be solved," added Tandon. TPAs admitted that there is some problem related to PPN rates but dismiss the allegation that there is delay in payments. An official of Oriental Insurance pointed out that few hospitals are charging extra over PPN rates from patients.

Basu, on the other hand, accused TPAs of being unprofessional. "They don't operate on weekends and respond late. Since emergency hospitalizations can't wait, they should be made to work 24x7," said Basu.

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